Our dental laboratory has recently observed a trend by specialists purchasing intraoral digital scanning systems for the purpose of providing restorative solutions to their referring clinicians.

digital planning of implant placement

The rationale is ostensibly driven by the specialists’ desire to improve communication with the referring clinician and to streamline the process in order to achieve a timely and successful outcome.

This altruistic effort by our specialists is noble but, if not properly communicated to the clinician, lab, specialist and, most importantly, our trusting patients, the process can lead to unmet expectations and unfulfilled promises.

As we all know, communication is key when developing cases that require an interdisciplinary protocol. At this point in this new digital process, distinct guidelines will need to be established in order to achieve clinical success and to provide a positive experience for our patients.

In this article, we will try to initiate some dialogue and ask some questions that can lead to a mutually acceptable sequence of events for a predictable outcome.

Questions for the patient

  • What are their expectations?
  • Do they know that they play the primary role in the process, since they are the ones receiving the benefits of all of our efforts?
  • Do they understand the risks that are involved to achieve a positive outcome?

Questions for the referring clinician

  • Should they be responsible for the final outcome?
  • What should his or her role consist of with this new paradigm?

Questions regarding prescriptions and scans

  • Who is fulfilling the prescription for the lab?
  • Should the specialist be responsible since he or she is the one scanning and sending the case to the lab?
  • Who pays the lab? The specialist who did the scan and who sent the scan to the lab or is it the referring clinician since they are inserting the case? 
  • Does the referring clinician assume responsibility for the prescription since he or she is ultimately in charge of the final delivery?

Contingency questions

  • If the final outcome is unfavorable, who should assume financial responsibility for the additional lab remake fees?

In order to delve deeper into this new protocol, the motives of the specialists who do these scans must first be scrutinized. They are obviously attempting to build a more trusting relationship with their referral base, and they are being sensitive to the productivity concerns of their referring clinicians. They understand that there are true benefits of this protocol if it is properly managed and executed.

Let’s now ask some clinical questions regarding this protocol in order to achieve a favorable outcome for our patients.​

Questions for the specialist prior to placement

  • What information should the specialist have before placing the implant
  • Do the referring clinician and lab need to even get involved?
  • Perhaps another way to phrase this question would be: How much of the restorative treatment plan needs to be understood by the specialist before he or she can circumvent the restorative design information from the referring clinician and lab?

Questions regarding clinical decisions and responsibilities

  • Who is ultimately responsible for the final decision on the position and diameter of the implant? Criteria would include depth of the placement, diameter of the implant, buccolingual spatial relationship and mesiodistal spatial relationship.
  • Who should make the final decision on the type of implant and what restorative materials to use?
  • Who makes the decision on cement-retained or screw-retained restorative solutions?

Questions regarding the specialist’s background and expertise

  • Is the specialist adept at identifying path of insertion issues and occlusal problems? For example, when the clinician refers an implant case to the specialist, and the specialist identifies bite collapse where there would be a contact point near the occlusal surface resulting in a large, open embrasure, is the specialist obligated to alert the referring clinician to this potential path of insertion restorative problem?
  • Does the specialist have the clinical restorative background to identify occlusal discrepancies related to bite collapse or interocclusal space deficiencies that would compromise the final restorative design?
  • How should the specialist communicate this to the referring clinician?

Questions regarding lab responsibilities

  • At what point should the lab be involved in design and fabrication?
  • What is the responsibility of the lab if it identifies potential problems after the digital file is received from the specialist with a prescription to fabricate?
  • Who should the lab call first? The specialist who did the scan or the clinician who referred the case to the specialist?

Questions regarding specialist involvement in this case

  • In the esthetic zone, typically a preoperative DICOM (Digital Imaging and Communications in Medicine) file from the specialist’s CT is overlayed with the digital restorative STL file from the referring clinician or from the lab to determine implant diameter, spatial relationship and depth to allow for a proper emergence. How important is it to get the referring clinician involved in this part of the planning process before implant placement and scan by the specialist?
  • Does the referring clinician typically need to get involved at all?

Questions regarding provisionalization, design and the esthetic zone

  • Immediate and early provisionalization in the esthetic zone seems to be gaining some traction as the new standard of care if acceptable torque values are achieved and occlusion is addressed at the time of implant placement. How is the design for emergence and soft-tissue management addressed?
  • Should the specialist be responsible for the scan at the time of placement, or should the patient be sent back to the referring clinician for them to scan or take a physical transfer impression to be sent to the lab?
  • Who is responsible for emergence management of the implant in the esthetic zone during the provisionalization process?

It should be the belief of our profession that scanning by specialists will work if a protocol is established that allows our patients to receive a predictable outcome with minimal disruption to their daily lives. But, as we all can see, there are many questions that will need addressed before a distinct treatment path emerges from our dialogue. The intent of the narrative here is to stimulate discussion on this new approach to treating our patients in this manner.

Dr. Edward Roman, D.D.S. https://www.romanvaughan.com/

Comments

Commenter's Profile Image Douglas S.
August 20th, 2018
Thanks for writing this article. As an Oral Surgeon who has been Cerec scanning patients for 4 years, these are great questions which need to be answered. I actually got involved in scanning so I could send out prosthetically driven guides. Scanning after the implant is placed is nice, but not as important as putting it in the right way the first time.
Commenter's Profile Image Craig V.
September 26th, 2018
We have been scanning patients with Trios for almost a year now. There is definitely a learning curve for the people doing the scanning (for us it is the trained staff members and the surgeons who review the scans). Just like everything else we do, the more you do, the better you get. I can tell you it has been a welcome addition to the Oral & Maxillofacial Surgery practice. We can use it to help with Orthognathic Surgery planning, dental implant planning, fabrication of different types of temporaries, etc. It is especially helpful with impressions needed on Sleep Apnea patients with large tongues and severe GAG reflexes, patients with minimal mouth opening, small mouths, patients with large tori, etc. I would recommend starting with a select number of referrals who are progessive in their thinking and want to "help" you get this right. When you get it "right", it definitely streamlines the dental implant process making things much more convenient for patients and referrals. Craig E. Vigliante MD, DMD